Sheila Ryan Barnett, MD Associate Professor of
AnesthesiologyHarvard Medical School
Beth Israel Deaconess Medical Center
Boston, MA
Population
USA
> 65y
>85 y
16,000,000 surgeries per year
60% of patients of general surgeons > 65y
Growth in specialty surgery expected: 35-47%
Frequency of 12 common procedures
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Li et al Anesthesiology 2009; 110: 698-9 US 1999 – 2005
Aging & comorbidities Medications – modifications Medications – to avoid Risk reduction Inevitability
Aging involves physiological changes
AND
The pathophysiology of superimposed disease
Steady Age-related Decline in Organ
Function
> 80y
DISABILITIES COMMON
What is your elderly patient’s functional reserve?
Goal of the preanesthetic assessment
Minor complications poorly tolerated
Vascular stiffening, HTN, loss elasticity Ventricular
• Increased impedance - wall hypertrophy • decreased compliance, atrial dependence
Conduction issues: • Decline in pacemaker cells, increase in atrial ectopy,
& conduction defects Reduction in maximal HR –
• reduced response to catecholamines Increased ischemic heart disease
Diastolic Function
Classification
% LVEF
Normal 37% 54%
Mild to Moderate
57.9% 54.5%
Moderate 3.9% 54%
Severe 1.7% 43%Philip Anesth Analg 2003 ; 97 1214-21
Diastolic E/A : deceleration time / 250 pts /72 y
61.5%
Thorax stiffens:• reduced chest wall compliance & decreased thoracic
skeletal muscle mass = Increased work of maximal breathing
Lung volumes change – reduced reserve volume Decrease in elastic lung recoil – closing volume
increase More V/Q mismatch & greater P(A-a) O2 gradient
Reduction in hypoxic and hypercarbic drive
Increased narcotic-induced apnea Decreased pharyngeal reflexes - ? More aspiration
At age 80 paO2 is about 58 mmHg !
Close to the edge at the start !
• Case controlled study of Spinal surgery patients
• Compared patients with & without Surgical Site Infection (SSI)
• Independent risk factors: – Long surgery OR 4.7 p<0.001– ASA 3 + OR 9.7 p< 0.001– Obesity 4.0 p<0.01– Intraoperative oxygen <50% OR 12 p <0.001
• Potential impact for elderly ?
Maragakis Anesth 2009; 110:556-62
Cortical grey matter attrition – • starts in middle age
Cerebral atrophy – disease vs. aging
Increased intracranial CSF
CBF and auto regulation largely maintained
Postoperative cognitive dysfunction
1. Appreciate reduction in reserve function
2. Understand age related organ changes and the impact of common disease
3. Beware of ‘under-diagnosis’ e.g. DHF & fluids
4. Provide supplemental extra oxygen, (increased risk hypoxemia)
Dose reduction • Pharmacokinetic • Pharmacodynamic
Interval extension
Anesthesiology 2009; 110:1050-1060
What Dose?
Dose response curve flattened in the elderly patient
JR Jacobs et al Anesth Analg 1995; 80:143
25 -50% reduction
50% reduction in initial doses for fentanyl
Significant decrease in pharmacodynamic response
All opioids increased risk apnea & hypercapnia
Increased & delayed hemodynamic impact leading to hypotension
Anesthesiology 2009; 110:1050-1060
“Start low, go slow” Benzodiazepines
• Low dosing with Midazolam to start Opioids
• Beware respiratory depression• Titrate to effect
Reduce inhalation agent Complete reversal of muscle
relaxants
• Anticholinergic side effects – Central: Falls, delirium, cognitive dysfunction– Peripheral : Dry mouth, constipation, confusion
• Anticholinergic Risk Scale – List of drugs with varying anticholinergic
properties – Avoid or limit use if possible
• Beers Criteria – Long acting Benzodiazepines– Multiple medications , many with
anticholinergic properties
• High risk 3 points – Atropine products – Hydroxyzine (Atarax or Visteril) – Diphenyhydramine (Benadryl)– Promethazine (Phenergan)
• Intermediate 2 points – Prochlorperazine (Compazine)
• Low 1 point – Haloperidol– Metoclopramide ( Reglan)
Rudolph Arch Int Med 2008; 168:508-13
Active metabolites normeperidine • Renal excretion• T ½ 14-21 hrs in elderly up to 30 hrs with CRI
Causes myoclonus, twitching and seizures
Associated with delirium in elderly Not recommended: use of meperidine
in patients 75 yrs or older for analgesia is considered indicator of poor care by the Assessing Care of vulnerable elderly.
• Survey of 3000 community dwelling 57-85 y – 81% minimum of 1 prescription drug (PD)– 49% used dietary supplements – 29% used at least 5 PDs
• Among PD users 46% also used over the counter drugs
• 4% at risk of major drug interaction, half with non prescription drugs
• Anti-coagulants most commonly involved
Unknown true impact on the perianesthetic course
Qato JAMA 2008; 300 (24) 2876
1. Avoid meperidine, long acting muscle relaxants & benzo’s and anticholinergic
2. Look for Polypharmacy
Timing of surgery Comprehensive preoperative
assessments Beta Blockade … again
Meta-analysis of >250,000 hip fx pts
Mortality at 30 days and 1 year
When delayed over 48 hours • 41% increase 30 d mortality • 32% all cause mortality
How practical is this?
Shiga et al Can J Anesth 2008; 55:3; 146-154
120 patients >60 y CGA
• ADLs, IADLs (Barhtel Index) , comorbidity, nutrition, MMSE
All undergoing thoracic surgery
17% post op complications
Predictors – • Low Barthel Index • Surgery >300 mins • Dementia – low MMSE
Fukuse Chest 2005; 127:886
400 patients > 70 y Admitted to Intervention Ward
• Assessment, prevention treatment education Assessment day 1,3,7 Delirious patients in the Intervention ward
• Shorter duration: by day 7 30% vs 60% (p 0.001 )
• Shorter LOS: 9 vs 13 days (p 0.001)• Reduced mortality: 2 vs. 9 patients died (p 0.03)
Lundstrom et al JAGS 2005:53:622
Mangano NEJM 1996;335:1713• 100/200 patients received Atenolol
preop and for 7 days• Atenolol group improved survival 6
months & up to 2 y. Diabetes major risk
But later data mixed results with increased stroke and mortality
• Observational study
• 5158 THR/THR patients– 19% Beta blockers
• BB for 7 days (740) • BB DOS & d/c’ed (252) 25%
– No BB (4166)
• Total 1.5% (77) had POMI • BB continued -22 POMI; 7 deaths• BB discontinued -20 POMI; 19 deaths• No BB – 35 POMI; 28 deaths
• Event rate 3% BB vs. 7.9% for d/c’ed BB• In those discontinued beta blockers 2 fold increase in
POMI and death ( OR 2.0)
Van Klei et al Anesthesiology 2009; 111:117-24
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45,370 patients eligible for beta blockade
Vitagliano et al. JAGS 2004: 52:495
1. Careful preoperative assessment is a priority
2. Get to the OR in a timely manner 3. Risk reduction medication – possible
beta blockers 4. Role of blood transfusions (not
discussed)
Unanticipated day of surgery deaths – > 800 000 patients NSQIP - Death rate 0.08% – Older age 60 vs. 67y and males P<0.0001
• Complications increased death rate
• PACU/ICU transfer most unstable
• Opportunity to improve in 31% (chart review )
• Improvement: hypovolemia, MI and transport period
Bishop Anesth Analg 2008 107: 1924-35
Veterans Hospital Data • 26 648 > 80 y• 568 263 < 80 y
30 day mortality 8% vs. 3%, p<0.001 <2% if > 80y undergoing simple procedures
• TURP, IH, TKR, CEA 20% had complications in > 80y Once a complication – 26% vs 4% mortality
Hamel et al JAGS 2005; 53:424
Cardiac events post non cardiac surgery
7700 patients, 83 (1%) Cardiac event 9 independent predictors In patients experiencing a cardiac
event, intraoperative data more likely to show episode of hypotension +/- tachycardia
Kheterpal et al Anesthesiology 2009; 110:58-66
Avoid complications Hemodynamics
Turrentine et al J Am Coll Surg 2006; 203:865Surgical morbidity
Surgical mortality
300 unselected hip fractures All received similar multimodal
anesthesia & defined rehabilitation Outcomes:
• 30 d mortality 13% • >30d 7 more died
Combined mortality 16%
Foss & Kehlet Br J Anaesth 2005; 94: 24-29
47 deaths • 28% (13) unavoidable, terminal cancer
or refused care • 15% (7) probably unavoidable• 34% (16) potentially avoidable ; active
care curtailed• 23% (11) received maximal care ?
Potentially avoidable
Best outcomes if:
Avoid complicationsPreoperative optimization OR without delay (when feasible) ? Beta blockers / transfusions Age appropriate drug dosing Postoperative: pain meds, oxygen